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Neural Blockade in Clinical Anesthesia and Management of Pain, Volume 494

Intercostal nerve block


An intercostal nerve and its branches. Approximate area of skin supplied by bran
ches is also shown. There is evidence, however, that local anesthetic injected n
ear the lateral cutaneous branch diffuses posteriorly to reach the posterior cut
aneous branch. Note also (i) the spinal nerves and dorsal root ganglia in the re
gion of intervertebral foramen, with risk of perineurial spread into spinal fluo
id after intraneural injection in this region; (ii) direct injection into an int
ervertebral foramen may reach spinal fluid by means of dural cuff (iii) logal an
esthetic may gain access to epidural space by diffusing into an intravertebral f
oramen; and (iv) close to the midline the intercostal nerve lies directly on the
posterior intercostal membrane and pleura. (v) Paravertebrally, solution may di
ffuse to rami communicantes and symphatetic chain.
Technique
Technique Intercostal nerve block may be performed at several possible sites alo
ng the course of the nerve. The most common, the posterior approach, offers seve
ral advantages, and is perforemed at a site in the region of the angle of the ri
bs just lateral to the sacrospinalis group of muscles, 7 to 8cm lateral of the m
idline. At this location, the posterior intercostal membrane is impermeable. Lat
eral to this, the internal inter-costal membrane becomes the internal intercosta
l muscle which may permit local anesthetic solution to diffuse out of the interc
ostal groove and into the external intercostal muscle. Furthermore, the ribs and
intercostal spaces are thicker at the angle of the rib, allowing a larger margi
n of safety, before pleura is contacted. For technical ease of performance and f
or optimal teaching or learning experience, the patient is best placed ina
Advanced Therapy in Thoracic Surgery
edited by Kenneth L. Franco, Joe Billy Putnam
Mechanism of action
Intercostal nerve blocks produce analgesia by direct blockade of the intercostal
nerves. There is usually minimal or no spread of anesthetic proximally to the d
orsal rami of the intercostal nerves or the symphatetic chain.
Contraindications
There are no absolute contraindications specific to intercostal nerve blocks. Th
e main relative contraindication of intercostal nerve blocks when used for post-
thoracoctomy analgesia is in patients for whom the effects of high systematic bl
ood levels of local anesthetic may be particulary detrimental, which includes pa
tients which includes patients with cardiac conduction defects and seizure disor
ders.
Advantages and disadvantages
ICNB require little training and no special equipment. The technique is quite sa
fe, and any significant complication occurs within 30 minutes of performing the
block. As such no special monitoring necessary for patients with these blocks be
yond immediate post-block time period.
The main disadvantages of intercostal blocks are the ncessity of performin separ
ate blocks at multiple levels and the relatively short duration of analgesia ach
ieved via the single-injection techniques.

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